CHAPTER 10

OVERCOMING FEAR
OF DEATH

WHY CONSIDER DEATH ANXIETY IN THE ASSESSMENT

AND TREATMENT OF HEALTH ANXIETY?

Fear of death is common in the general population. Agras, Sylvester, and

Oliveau (1969) reported that 16% of their community sample reported
fear of death and 3.3% reported intense fear of death. In a more recent
community study by Noyes and his colleagues (Noyes et al., 2000), 3.8%
of respondents indicated they were much more nervous than most people
about death or dying and 9.8% indicated they were somewhat more nerv-
ous than most people. Developmental studies (Kastenbaum, 2000)
indicate that children generally become aware of the issue of death at the
preschool level and their understanding of death typically evolves toward
a view of death similar to that of adults by the age of ten.
Fear of death is also common in individuals with hypochondriasis.
Kellner et al. (1987) compared matched groups of psychiatric outpatients
with hypochondriasis, outpatients with nonpsychotic psychiatric disor-
ders (not including hypochondriasis), outpatients in a family medicine
clinic, and workers at local companies on subscales of the Illness Attitude
Scales (Kellner, 1986). They found that patients with hypochondriasis
were much higher than all the other groups on the subscales for
Worry about Illness, Concern about Pain, Hypochondriacal Beliefs,
147
148 CHAPTER 10

Thanatophobia (death phobia), Disease Phobia, Bodily Preoccupation,

and Treatment Experience (use of health services). The other three groups
did not show statistically significant differences from each other on the
measure of Thanatophobia.
Noyes et al. (2002) studied the relationship between fear of death and
hypochondriasis in a sample of 117 women and 45 men attending a
general medicine clinic at the University of Iowa. They found a high cor-
relation between scores on a fear of death scale and measures of
hypochondriasis, somatization, and health anxiety. Those patients who
met DSM-IV diagnostic criteria for hypochondriasis scored considerably
higher on the fear of death scale than patients who did not meet criteria
for hypochondriasis.
Just as an individual may have specific phobia of illness that does
not meet the criteria for hypochondriasis (Noyes, Carney, & Langbehn,
2004), some individuals have specific phobia of death without
hypochondriasis or specific fear of illness. Noyes and his colleagues note
that specific phobia of illness may arise in the context of a medical illness
or a related threat to health and these phobias may be more common in
people with medical problems. We also see some individuals with seri-
ous illness (cancer, chronic obstructive lung disease) who struggle with
an intense fear of death. The treatment may be adapted to these special
situations.

DEATH ANXIETY AS A NORMAL EXPERIENCE

Just as anxiety is a normal emotion, anxiety concerning death is also a
normal experience. In his book The Psychology of Death, Kastenbaum
(2000) provides a comprehensive review concerning attitudes about death
in Western culture. He suggests that views about death develop during
the preschool years and evolve through childhood and adolescence. There
has been extensive research on death anxiety in nonclinical populations.
The overview of this research by Kastenbaum (2000) suggests a number
of consistent findings:
1. Most respondents in the community do not report a high level of death
anxiety.
2. Females report higher levels of death anxiety than males.
3. In cross-sectional studies, older people do not generally report higher
levels of death anxiety than younger people even though they are
clearly closer to death. Specific concerns about death differ at different
ages and in different life situations.
OVERCOMING FEAR OF DEATH 149

4. Higher levels of education and higher socioeconomic status are

modestly related to lower levels of death anxiety.
5. Higher levels of religious belief and participation in religious practice
are not associated with lower levels of death anxiety.
Kastenbaum points out that the modest level of death anxiety that most
people experience in everyday life may increase dramatically when the
individual experiences a period of stress or threat, such as health
problems, illness, or death of someone close.

ASSESSMENT AND TREATMENT OF DEATH ANXIETY

It is important for the clinician to ask clients about fear of death during
the assessment process. As noted in Chapter 5, several self-report ques-
tionnaire measures provide information about death anxiety and atti-
tudes toward death, including the Death Anxiety Scale (Templer, 1970)
and the Multidimensional Fear of Death Scale (Hoelter, 1979). If it is clear
that death anxiety is a concern, it is helpful to ask a few follow-up ques-
tions to develop a better understanding of the problem. We ask every
client whether they worry a lot about death and dying. If they indicate
yes, we ask a number of other questions to broaden our understanding of
the problem:

● Could you tell me more about your worries about death? How often do
these worries come to you? How do you react when you experience
these worries?
● When did you notice that you started to have more concerns about
death than most people? Were there any extra stresses in your life at that
point?
●
What have your personal experiences with death been like over the
years? Could you describe them?
● Are there situations you avoid because of concerns about death?
● How do you cope when you are dealing with anxiety about death?

Even though there is a very extensive literature on death anxiety

(Kastenbaum, 2000; Neimeyer 1994), to our knowledge there are no con-
trolled studies on the treatment of death anxiety in a clinical context.
Studies of CBT treatment of hypochondriasis and other forms of health
anxiety (reviewed in Chapter 4) generally do not report the impact
of treatment on measures of death anxiety. A few case studies
150 CHAPTER 10

describing treatment of hypochondriasis or illness phobia indicate that

the participants had high levels of death anxiety. Tearnan, Goetsch, and
Adams (1985) describe the treatment of disease phobia in a young man
who described the onset of intense fear of having a heart attack and
dying, following the sudden death of his father-in-law due to a heart
attack. The treatment involved exposure to a range of disease-related sit-
uations, including imaginal exposure to cues related to death from a
heart attack. The client was much improved by the end of treatment and
maintained the improvement at follow-up. Papageorgiou and Wells
(1998) describe the use of attention training as a CBT intervention with
three clients (all age 65 or over) with the onset of hypochondriasis and
prominent fear of death more than 10 years earlier, after the death of
family members. All the participants had a very positive outcome
with attention training as a single component treatment, with no
work on exposure, response prevention, or cognitive change beyond the
refocusing of attention.
Generally, empirical studies of assessment and treatment of
hypochondriasis and other forms of health anxiety do not include a
specific focus on fear of death. Since there is good evidence for the effec-
tiveness of current CBT interventions, why should we consider adding
specific assessment and treatment of death anxiety? Simpler treatments
are easier to disseminate and implement. In our opinion, however, it is
worthwhile to consider death anxiety in our interventions because death
is so commonly encountered in the media and in the events people
will experience during their lives. Treating health anxiety without deal-
ing with death anxiety leaves clients at risk for return of symptoms
when they encounter death-related events. Clearly, this area warrants
future research.

A PRACTICAL APPROACH TO TREATMENT

Exposure
A detailed case formulation, as described in Chapter 5, informs treatment
planning. Avoidance is one of the most common ways of dealing with fear
of death. People often avoid thinking or talking about death until it
intrudes into their life in some way. Consequently, it is helpful to provide
clients with a rationale for dealing with the issue of death more directly
in therapy. Handout 10.1 describes the rationale and instructions for
exposure treatment that we use for death anxiety.
OVERCOMING FEAR OF DEATH 151

Handout 10.1. Overcoming anxiety about death.

Why face the fear of death?
One of the challenges that all of us face as the years go on is coming to terms with
the reality of death. Working to cope with fear of death may be very helpful in
coping effectively with anxiety.
Every living thing will eventually die. The chair you are sitting on will never
die, but it will also never live. Death is a part of the normal flow of life. There can-
not be life without death. This is one of the things that make life so precious – from
the life of a flower, to the life of a pet, to the life of a family member, to our own
life. This is one of the reasons that it is important to appreciate and enjoy life while
we have it.
An important part of being able to enjoy life and cope with its challenges is to
be able to deal realistically with death. Most people are able to come to terms with
the issue of death as the years go on. This applies both to people with traditional reli-
gious beliefs and to people with nontraditional or no religious beliefs. It may be
important to consider where you stand on the issues described by the world’s reli-
gions, but it is not necessary for you to hold traditional religious beliefs to deal with
the issue of death.
One of the ways of coping with death is to see the balance in life. In any friend-
ship, for example, a part of the relationship is that you will have to say goodbye
some day. One of you will move away or be unavailable or come to the end of life.
One day the relationship will end. Some people try to cope with the reality of loss
by deciding that they will never have a friend. If you do not have a friend, you can-
not lose a friend. This approach protects people from loss but at a huge cost. They
give up many days of happiness and satisfaction that come from a good friendship
to prevent the smaller number of days of sadness when a friendship ends. Most peo-
ple would rather take the positive experiences that a friendship can bring and accept
that there will be sadness when the relationship comes to an end.
There is a similar balance that applies to life in general. Most of us have the
opportunity for many more days of happiness and satisfaction than the days of
sadness we will experience when we are saying goodbye to life. The secret of a
good life is to treat life as very precious and to live life so that we have many days
of happiness as possible. Time passes quickly and many of us will be saying good-
bye to life at a time when we would still like to have a few more healthy years.

The reality of death

Avoiding the issue of death seems to work for most people most of the time.
However, at times the usual ways of coping are compromised by intense
stress or experiences with death and illness. People may find themselves con-
stantly preoccupied with fears of death, illness, accident, injury, and harm.
These fears create distress, limit pleasure and satisfaction in life, disrupt rela-
tionships with other people, distract from working effectively, and consume
unnecessary energy.
152 CHAPTER 10

Fears of illness and death are different from many other fears. Many of the
things that people fear are unlikely to happen. People who are afraid of flying, for
example, are extremely unlikely to be injured or killed in a plane crash. People
who are afraid of dogs are unlikely to be injured by a dog. All of us will have to
deal with serious illness at some time in our life, however, and all of us will die.
As the years go by we will also have to deal with illness and death in people who
are close to us.
Some people are so preoccupied by their fears of death that this fear con-
sumes much of their attention and energy. They feel that they cannot enjoy any-
thing unless they can be certain that they will not be dying soon. Without
realizing it, they use up the precious days of life worrying about something that
may not happen for many years. They were converting possibly happy days into
unhappy days. Other people are able to accept the reality of death, come to some
peace with the idea, and trust that they will be able to cope with these situations
when they come up. They can focus on the task of living a satisfying and happy
life.

Facing your fear of death

The most powerful way to deal with fear of death is face the fear rather
than avoiding it. At first glance, this may seem foolish to you. You might say
that you are distressed because you are preoccupied with death at every
moment. How much more can you face it? How will that help you to feel better?
There is, however, a difference between being preoccupied with death and facing
and accepting it. We have learned that the best way to overcome fear, including
fear of death, is to face the feared situation. Usually it is best to face the fear
gradually, a step at a time. The idea of facing one’s fears can be quite frightening,
at first, but usually this can be accomplished in a way that is not too difficult
or painful.
Philosophers suggest that we can only make the best of life when we are able
to understand and accept the reality of death. We have all heard stories of people
who have faced death and felt their lives changed by that confrontation. Dr. Irvin
Yalom has worked extensively with terminally ill cancer patients and describes
the startling, inner changes that many of these individuals experienced as they
faced death. Some of the forms of personal growth he noted were:

1. Deciding what is important in life and what is not important. Not being
troubled by unimportant matters.
2. A sense of liberation: being able to choose not to do those things that they do
not wish to do.
3. An enhanced sense of living in the immediate present, rather than postponing
life until retirement or some other point in the future.
4. A vivid appreciation of the elemental facts of life: the changing seasons, the
wind, falling leaves, the last Christmas, and so forth.
5. Deeper communication with loved ones than before the crisis.
6. Fewer interpersonal fears, less concern about rejection, greater willingness to
take risks, than before the crisis (Yalom, 1980, p. 35).
OVERCOMING FEAR OF DEATH 153

You do not have to be near death to benefit from facing and accepting it. The aware-
ness of death can help you live your life with greater pleasure and satisfaction every
day. In helping people come to terms with death we have found that two approaches
are helpful. One approach is to overcome your fear of death by facing the reality of
loss and death. The second approach is to resolve to live life to its fullest and to get
as much enjoyment and satisfaction as possible from each precious day.

Activities to face death anxiety

We have found it helpful to use some of the following exercises in work on over-
coming death anxiety:

1. Write a story about your own death that includes your worst fears. Use this
story for 30–60 minutes each day to help you to vividly imagine situations
where you would have to face death.
2. Consider any situations that come up in life that you avoid because of anxiety
about death. If these are situations that other people would face and that you
would like to face, make a plan to face these situations in gradual steps with
repeated practice until the anxiety is reduced.
3. If you do not have a will already, prepare a will. If you do have a will review
it and make sure it is up to date. There is usually material at the local library
or bookstore to assist in preparing a will. It is wise to consult a lawyer about
taking the proper legal form in finalizing a will.
4. Write your own obituary using as examples obituaries from people of your age
in the local newspaper. (The obituary should be for your current age, not for
ten years down the road.) Review and save in a file the obituaries of people
close to your age. In reviewing the obituaries imagine what the circumstances
might have been around the death.
5. Decide what you would like in terms of funeral arrangements. There may be a
local funeral planning society or funeral home that can provide information
about choices. Consider whether you would like to follow some family or reli-
gious tradition or to plan something that fits with your beliefs and interests. If
you are in a relationship discuss these preferences with your partner or a close
family member or a friend.
6. Practice dealing with first person accounts of someone (especially someone
who is similar to you in some ways) coming toward their own death or the
death of a close friend or family member. This may be done through books,
magazines, television programs, or movies. This is even more helpful if the
cause of death is one of the areas you fear.
7. Visit the grave of a family member or friend.
8. Visit a place that is associated with death for you such as a hospital emergency
department, a funeral home, any other place that others would visit but is dif-
ficult for you because of death anxiety.
9. Write about or make an audio tape describing a difficult past experience of
terminal illness or death that involved a family member or a friend. Use the
written account to clearly imagine and face these difficult memories.
© 1998 by Furer and Walker
154 CHAPTER 10

In planning exposure, pacing is very important. If fear of illness is

prominent for the client, this is often tackled earlier in treatment with a
focus on fear of death coming later. It is important to pace the exposure so
that the client moves quickly enough to be able to see progress but not so
quickly that she feels overwhelmed. We often describe a variety of possi-
ble exposure assignments and ask clients which areas they feel ready to
work on first. Having clients who write an exposure narrative about their
own death is particularly helpful. Some people express concern that if they
write a story about a feared future event, their fears will come true. One
humorous way we have found to deal with this fear is to ask the client to
first write a story about the therapist’s winning the lottery. (Sadly, we have
yet to win anything this way.) Clients identify the point of this quickly and
this often reduces their reluctance to write the story of their own death.
Clients who fear the death of a close family member (parent, spouse,
child) often benefit from writing a story about this situation. Many people
find this exercise more difficult and emotional than writing about their
own death and they may require additional support in working on this
task. For some individuals, there may be issues regarding past losses that
benefit from therapeutic attention and an exposure approach (e.g., facing
the memories and feelings associated with the loss).
Handout 10.1 includes a variety of exposure assignments that are
suitable for many clients, such as preparing a will, making funeral
arrangements, and writing their own obituary. Exposure to situations that
have been systematically avoided is particularly important. To facilitate
exposure, it is helpful to have some resource material available, such as
funeral planning material and the titles of books and movies dealing with
death issues. Elizabeth Kübler-Ross has written extensively about coming
to terms with death. She edited an excellent series of accounts from
individuals, family members, and friends addressing death issues
(Kübler-Ross, 1975). Sherwin Nuland’s book, How We Die (1994), provides
detailed accounts both from a medical perspective and in the first person
of how people die from common causes such as cancer, heart disease,
Alzheimer’s disease, accidents, and crime. Although the content is diffi-
cult, the presentation is compassionate. In planning assignments it is
important to plan for exposure to be repeated often enough and for
adequate time periods so that there is a significant reduction in anxiety.
Given how common the discomfort with issues regarding death is in
our culture, it is not surprising that many family members of the client are
also uncomfortable with some of these assignments (e.g., making a will,
considering funeral arrangements). It is useful to help clients to prepare
for discussions with these family members. Naturally, the therapist must
OVERCOMING FEAR OF DEATH 155

use clinical judgment about the best timing for these assignments. We
tend to introduce them early in therapy but if a client is depressed and
reporting suicidal thoughts, clearly we would focus on treating depres-
sion first and would not focus on death anxiety until there was a clear and
persistent improvement in mood.

Cognitive Reappraisal
Certain thoughts and beliefs about death are common. In exploring this
area, it is helpful to review clients’ personal experiences with death.
Helping the client to move toward more balanced views of these issues
may help them to cope more calmly with the prospect of death. Therapists
may be able to provide corrective information based on their personal
experiences with illness and death. Handout 10.2 lists some of the unreal-
istic beliefs about death that we commonly encounter and some more
realistic beliefs for the client and the clinician to work toward.

Case Example
The initial assessment with Anna, age 35, indicated that death anxiety,
beginning in late adolescence, was her main concern. She reported no cur-
rent problems with fear of illness or somatization. A review of her current
situation indicated she was very satisfied with her work and family life.
Her enjoyment of everyday life was very solid, so in this case (unlike
many others) it was not necessary to focus on the enjoyment of life. She
produced this very eloquent story later as part of her work in imaginal
exposure.
For many years now, I have been preoccupied with worries about money, career,
relationships, and material things. As the years passed, I spent little time think-
ing about the broader picture, the meaning of my life. From time to time, I have
had anxiety about death but I never really thought about it realistically, that it
could really happen to me. It was always just a fear that I tried to push aside
and not think about. That is why what is happening to me now has hit me like
a thunderbolt.
156
Handout 10.2. Challenging your beliefs about death.
Unrealistic belief
● If I find out that I am going to die, I will
not be able to cope with my feelings.
My emotions and actions will be so out
of control that I will be in constant
emotional suffering. This may create
great distress for those around me.
● Dying is likely to involve terrible pain
and suffering in addition to terrible fear.
● If I die before my children are grown,
it will ruin their lives forever.
● I would not be able to cope with death
because I do not have a religious faith
that gives me confidence and peace in
what comes after death.
CHAPTER 10
More realistic belief
● Many people are understandably
frightened when they find out that
death is approaching. They manage to
cope with these emotions as time goes
on and most people approach the end of
life with dignity. This is also true of
people who have a lot of anxiety
about death.
● Most of us will have many days of
health and happiness in our lives.
Unfortunately, most of us will also have
some days of illness and pain. People
have help to deal with the illness and
pain and are able to get through this with
a good deal of support. Relief of pain is
now a high priority in treatment of the
dying.
● Leaving my children behind will be
difficult but there are other people who
care about them who will help them. It is
important to do the best job possible of
parenting now. Part of this job is making
sure that the children have others who
care about them.
● People with all different types of
religious beliefs, including no beliefs,
cope well with death. It is valuable to
consider your philosophy about life
and death.
OVERCOMING FEAR OF DEATH 157

A few months ago, I noticed that my vision would get blurred and from time
to time I would have trouble getting up quickly from sitting to standing. I would
feel dizzy for a couple of seconds. But I didn’t take it seriously and went on with
my life as usual. However, as the weeks progressed, I started having migraines. At
first, they came once a week, but then they started to be more frequent. I made an
appointment with the doctor. I hoped that these physical changes were hormonal
or related to my diet. The doctor gave me a complete physical and found nothing
wrong with me. At first I was relieved because I didn’t want anything to be found.
But the symptoms only progressed and I started to feel that maybe I needed to see
a neurologist to get to the bottom of the matter.
During the weeks that led up to my appointment for a CT scan, I was very
nervous. I felt the nerves in my chest and I was often short of breath. I worried
that I would die young. I had concerns about how my family, in particular my
children, would cope. The idea of not having control over my body or my mind
scared me. What concerns me the most is the physical manifestation of my own
death. I am an atheist. I wish I wasn’t. Believing in the afterlife would be a relief.
But I can’t believe what I don’t believe. To me, death is mechanical. It is a turn-
ing off, a closing down of the mind. That idea is morbid to me. I’m the center of
my existence. I’m afraid of not seeing, not hearing, not knowing what is happen-
ing around me or what is happening to my body. I can’t accept the idea that
I will be underneath the ground. It’ll be cold there and my body will freeze.
In the summer, it will be hot and my body will rot. My skin will shrivel up and
my organs will decompose. I’m afraid of the world going on without me. I’m sure
this seems egotistical. But I’m all that I’ve got! After I die, there is no ME any-
more. I will disappear and never reappear again. There will never be another ME
in history, for as long as the world exists, forever and ever. The inevitability of
death makes me feel trapped. I can’t escape it no matter what I do. I feel chained
to this ultimate course of life. I feel doomed!
After the CT scan, I try to forget about my fears. I call the doctor three days
later to find out the results. My heart is beating so rapidly. It feels as if it’s
pumping right through my chest as I wait on the phone for her to answer. The
doctor finally answers the phone and tells me she has bad news and that the CT
scan results showed that I have a brain tumor. I feel the blood drain from my face.
My worst fears have come true. I ask if she is sure and she says, “I’m afraid,
yes.” How is that possible? I ask if there is something to do about it, and she
says, “The tumor has already spread and is incurable.” I only have a few months
left to live.
I feel as if I’ve entered the abyss. I’m still alive but my life seems no
longer to belong to me, to be under my control. We go home and I go straight
to bed. I want to be unconscious for a while so I won’t have to think about
158 CHAPTER 10

this. That night, my husband and I sit down to tell the children that I’m
“going away.” They ask for how long, and we say “I’m going to heaven and
that I will meet them there.” Even though I don’t believe this, I feel it’s the
best way for them to cope with my death. They start to cry and we all cry
together and hug and don’t want to let go. I feel so sorry for them. I feel that
this will shatter their own lives, it’ll change who they are and I don’t know if
they will be able to cope. My son looks terrified and my daughter is confused.
I can’t do anything to save them from this. It makes me feel very sad and
utterly hopeless. I think about their deaths someday and that this life is a
tragedy. What is life worth if it all funnels into the same waste? I apologize
to them over and over again and tell them that I love them and will always
love them no matter what.
Two months later, I’m admitted to hospital. The cancer has taken over my
brain and I am having trouble thinking and speaking coherently. My head hurts
constantly and I am given pain relief. I feel dizzy all the time and have lost my
appetite. I have nightmares that I won’t wake up. I’m afraid to fall asleep. I can’t
come to accept this fate. I’m fighting it. But I’m not winning. On the tenth day,
with my family around me, holding on to me, I feel that I am losing conscious-
ness. I try to talk. I want to say “goodbye” and tell them that I love them for
the last time. But I can’t say the words. All I can feel is their touch, their hands
holding my hands and I hold on as tightly as possible. I try to see them clearly
but they are a blur and I would do anything to snap out of this condition. I gasp
for breath. I try to force air into my lungs but they feel like they’re closing off. My
head feels heavy and my eyes close. I am not at peace. I need more time. I’m not
ready. But then, in a moment, I am gone.
Anna and her husband did not have a will, despite having young children,
so they quickly arranged to complete a will. Anna also found it helpful to
work out plans for funeral arrangements, even though the discussion of
this area with her husband was emotionally challenging. With practice in
using her story to assist imaginal exposure, she found that there was a
steady decrease in her anxiety about death.
OVERCOMING FEAR OF DEATH 159

CONCLUSION

Death anxiety has been a neglected area in the research on treatment of

health anxiety. Clinical and epidemiological studies indicate it is a fre-
quent problem. This problem may be approached with CBT in a similar
way to other aspects of health anxiety. This approach is well accepted by
patients and appears to work well in clinical applications. It will be
important to evaluate the impact of treatment of death anxiety in
controlled studies.